A nurse is collecting data from child who has measles. Which of the following manifestations should the nurse expect to find?
Beefy, red tongue
Paroxysmal cough
Peeling of the hands and feet
Fever
The Correct Answer is D
A) Beefy, red tongue: The beefy, red tongue is typically associated with scarlet fever, a bacterial infection caused by group A Streptococcus. This condition can lead to a red, "strawberry" tongue, often accompanied by a rash. While measles can involve a variety of symptoms, including a red rash, conjunctivitis, and cough, the beefy red tongue is not characteristic of measles. In measles, the more notable symptoms are a high fever, cough, runny nose, and the development of Koplik spots inside the mouth.
B) Paroxysmal cough: Paroxysmal cough, which is a sudden, severe, and uncontrollable cough often followed by a "whooping" sound, is more characteristic of pertussis (whooping cough). While a cough is indeed present with measles, it is generally not paroxysmal. In measles, the cough is more persistent and associated with other typical symptoms such as fever and a characteristic rash. The coughing in measles may also be dry and harsh but does not tend to occur in violent, paroxysmal episodes like those seen in pertussis.
C) Peeling of the hands and feet: Peeling of the skin, particularly of the hands and feet, is more commonly observed in conditions such as scarlet fever, Kawasaki disease, or after a viral infection like hand-foot-and-mouth disease. It is not a classic finding of measles. In measles, the skin rash usually starts as maculopapular spots on the face and spreads down the body. While some skin sloughing can occur after the rash resolves, especially in severe cases, it is not the characteristic sign of measles, and it is not typically seen on the hands and feet.
D) Fever: Fever is one of the earliest and most prominent symptoms of measles. It typically appears about 2-4 days before the characteristic measles rash. The fever in measles can be quite high, often exceeding 104°F (40°C), and is associated with other symptoms such as cough, conjunctivitis, and photophobia. The fever usually persists for several days, and it is one of the critical signs that lead to the diagnosis of measles, particularly when combined with the characteristic rash and other respiratory symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) A recent move to a new city: A move to a new city is an example of an external stressor. External stressors are environmental or situational factors that create stress, such as life changes, events, or challenges in the outside world. Relocating can involve significant adjustments, such as adapting to a new community, finding housing, and establishing new social connections, all of which can cause stress.
B) Lack of nutritional knowledge: Lack of nutritional knowledge is an internal stressor, as it involves an individual's beliefs, attitudes, and understanding. While it can cause stress, it is a personal factor rather than an external, environmental one.
C) Report of feeling depressed: Feelings of depression are an internal stressor because they are related to an individual’s emotional state or mental health. This reflects the client's internal experience rather than an external environmental factor.
D) Recurring urinary tract infections: Recurring urinary tract infections (UTIs) are a health-related concern and can be seen as a physiological stressor. However, they are not strictly external; they are related to the individual’s health and body rather than external environmental circumstances.
Correct Answer is C
Explanation
A) "You owe it to your mother to take care of her now that she needs you.":
This response is not supportive and places unnecessary guilt on the son. Caregiving for a loved one with Alzheimer's disease is demanding, and expecting the son to provide care without considering his own needs is unrealistic. Guilt-tripping him may lead to burnout, as it does not acknowledge the emotional and physical strain of caregiving.
B) "You should think about placing your mother in a long-term care facility.":
While this may be a viable option for some families, this statement does not acknowledge the son’s emotional struggle or immediate need for support. Suggesting a long-term care facility may be premature without exploring other options and may cause the son to feel as though he is being pushed into a decision he is not ready to make.
C) "Let me give you some information about respite care for your mother.":
This is the most appropriate response. Respite care provides temporary relief for family caregivers, allowing them time to rest and recharge. It is a supportive approach that acknowledges the son’s exhaustion and provides him with a helpful resource. Respite care can alleviate caregiver burnout and help maintain the quality of care for the client.
D) "I think you should find other family members who could help your mother.":
While involving other family members can be helpful, this response does not provide immediate support or acknowledge the son’s current feelings of exhaustion. Suggesting that he simply find other family members may come across as dismissive of his current emotional state and may not offer the practical help he needs at this moment.
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